1. Overview of the Breast and Cervical Cancer Early Detection Program

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1 BREAST OR CERVICAL CANCER Legal Authority: 1902(a)(10)(A)(ii)(XVIII) of the Social Security Act 1. Overview of the Breast and Cervical Cancer Early Detection Program The Center for Disease Control and Prevention s (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides funding to all 50 states to provide low-income individuals with screening services for breast and cervical cancer. The Department of Health (DOH) Tennessee Breast and Cervical Cancer Early Detection Program (TBCCEDP) provides these screening services to individuals at DOH local offices throughout the state. The TBCCEDP provides clinical breast exams, mammograms and Pap tests for eligible individuals free of charge. In order to receive these services free of charge, an individual must be: Under a certain income level based on family size; and Uninsured, or insured by a health policy that does not cover these screening tests. All eligible individuals requesting an annual exam with cancer screening services are examined, and individuals of any age who report a suspicious symptom will be examined and referred for follow-up care as needed. An individual under the age of 50 and who is asymptomatic will receive a screening, but may have to cover an income-based nominal cost for the services. The Breast and Cervical Cancer Prevention and Treatment Act of 2000 allows states to offer individuals in the NBCCEDP access to treatment through the Medicaid Program. In Tennessee, eligible individuals receive Medicaid benefits in the Breast or Cervical Cancer (BCC) category. The CDC and CMS provide matching funds to the program, equal to the state s Medicaid Federal Medical Assistance Payment (FMAP). 2. Policy Statement TennCare Medicaid benefits are available to individuals who receive breast or cervical cancer diagnoses, including for precancerous conditions, through the TBCCEDP. Eligible individuals must require ongoing treatment for the cancer, meet all non-financial and financial eligibility requirements, and not be eligible in any other TennCare Medicaid or TennCare Standard category. Individuals diagnosed with breast or cervical cancer by the DOH may receive presumptive eligibility for the TennCare Medicaid program, if they are otherwise eligible. Presumptive eligibility provides coverage through the end of the month after the eligibility determination is made. 3. Presumptive Eligibility Presumptive eligibility for the BCC category is determined by the DOH. August 27, 2015 HCFA 1

2 a. Primary Screening Providers and Locations All DOH offices are expected to provide assistance to individuals who are diagnosed with breast or cervical cancer, or who have suspicious symptoms related to these two forms of cancer. Participating statewide providers, including local DOH offices and certain primary care clinics provide screening services. The program also works with the following community health centers: Matthew Walker Community Health Center Davidson County Meharry Medical Services Nashville Franklin Road Women s Center Nashville Memphis Health Center Christ Community Health Center Memphis Rural Medical Services East and Northeast Tennessee Memorial Hospital sites Chattanooga East Jackson Family Medical Center - Jackson A list of participating Community Health Centers is available on the DOH Breast and Cervical Cancer Screening Program web site: b. Presumptive Eligibility Requirements To be eligible for presumptive eligibility, an individual must: Have a verified diagnosis of breast or cervical cancer, including pre-cancerous conditions; Be under age 65; Be uninsured or lack creditable health insurance coverage; Participate in the TBCCEDP program; and Have income under 250% of the FPL, based on family size. NOTE: Self-attestation of income is accepted by TBCCEDP when determining presumptive eligibility. c. Presumptive Eligibility Benefits Presumptive eligibility benefits include TennCare Medicaid coverage not limited to the treatment of breast and/or cervical cancer, but it does not include experimental treatments. Presumptive eligibility extends through the end of the month following the month in which presumptive eligibility is established. If an individual files a HCFA application or applies through the FFM during that period, the individual s presumptive eligibility will remain open until final disposition of the application. August 27, 2015 HCFA 2

3 d. DOH Responsibilities i. Establishing Presumptive Eligibility Once the TBCCEDP determines presumptive eligibility, DOH staff complete the Presumptive Eligibility Form and fax it to HCFA. DOH staff will instruct the individuals eligible for presumptive coverage to apply for Medicaid through the FFM. HCFA staff will enter the individual s presumptive eligibility into the eligibility system. An approval notice is sent to the individual that confirms the 45 days of presumptive eligibility coverage, requests a plan for the individual s ongoing cancer treatment (see Section 5.g. below), and instructs the individual to apply for Medicaid through the FFM. ii. Services and Treatment-Related Expenses The DOH TBCCEDP provides all screening tests necessary to make a cancer diagnosis, as well as post-screening diagnostic services, such as surgical consultations and biopsy, to ensure that all individuals with abnormal results receive timely and adequate referrals. 4. Coverage under the BCC Category a. Applicants with Presumptive Eligibility Individuals who file a HCFA application or apply through the FFM during their presumptive eligibility period may receive continuous eligibility (i.e., no interruption between presumptive eligibility and TennCare Medicaid coverage) in the BCC category if they meet all non-financial and financial eligibility requirements. See all non-financial and financial eligibility requirements listed below. b. Applicants who Require a Referral to DOH TBCCEDP If TennCare Medicaid applicants indicate that they have breast or cervical cancer, and they are not eligible in an open TennCare Medicaid category, they must be referred to the DOH TBCCEDP program. If DOH diagnoses such an individual with breast or cervical cancer, or a pre-cancerous condition, the individual s presumptive eligibility may begin the date the initial HCFA application was received, if the date of the PE application is within 10 days of receiving the referral to DOH. When a referral is made, the case information should be ed to Frances Neal at [email protected]. 5. Non-Financial Eligibility Requirements a. Age Eligible individuals must be under the age of 65. August 27, 2015 HCFA 3

4 b. Citizenship Eligible individuals must be U.S. citizens, U.S. nationals or eligible non-citizens. c. Residency Eligible individuals must be residents of Tennessee. d. Enumeration Eligible individuals must possess and provide a valid Social Security Number (SSN) or proof of application for an SSN. e. TBCCEDP Participant Eligible individuals must be participants of the TBCCEDP program. They must have received a cancer diagnosis from the TBCCEDP and be approved for presumptive eligibility. f. Cancer Diagnosis and Ongoing Treatment Eligible individuals must have a diagnosis of breast or cervical cancer, including cancerous or pre-cancerous conditions, and require on-going treatment. In order to be continuously eligible in the BCC category after presumptive eligibility is established, individuals must submit a treatment plan to HCFA. The treatment plan is also submitted at each redetermination. Once a treatment plan is received by HCFA, it is reviewed by HCFA Member Services. Coverage in the BCC category provides full TennCare Medicaid benefits; however, TennCare Medicaid does not cover experimental treatments. g. Lacks Creditable Coverage Eligible individuals must be uninsured. An individual who lacks creditable coverage is considered to be uninsured. Creditable coverage includes: Other health insurance, including individual plans; Group health insurance plans; Medicare; Medicaid (Individuals applying for coverage will be screened for all open TennCare Medicaid categories prior to being determined eligible in the BCC category); Military health plans; Medical care programs of the Indian Health Services or tribal organizations; State risk pools; August 27, 2015 HCFA 4

5 Public health plans; Health plans under Section 5(e) of the Peace Corps Act. h. TennCare Medicaid Eligibility An eligible individual cannot be eligible for any other open TennCare Medicaid category. 6. Financial Eligibility Requirements Income and resources are not taken into account by HCFA when providing continuing eligibility in the BCC category after presumptive eligibility is approved. However, this information is required for processing the eligibility determination of other open TennCare Medicaid categories. 7. Coverage in another TennCare Medicaid Category If an individual receiving coverage in the BCC category gains eligibility in another TennCare Medicaid category, BCC coverage will close. This policy applies to all categories, except Emergency Medical Services (EMS) and both Presumptive Pregnancy and BCC. 8. Case Closure a. Presumptive Eligibility If an individual is diagnosed with breast or cervical cancer and is approved for presumptive eligibility, and the diagnosis is determined to be benign or the individual fails to provide necessary information for ongoing coverage in the BCC category (or other TennCare Medicaid category), the presumptive eligibility coverage will end the last day of the month following the month in which presumptive eligibility was established. b. BCC Eligibility Once an oncologist determines that the enrollee is cancer-free or in remission, the BCC category coverage will be terminated. Individuals losing eligibility in the BCC category will be reviewed for coverage in an open TennCare Medicaid category prior to termination. August 27, 2015 HCFA 5